Application for student enrollment in Martial Arts  Admission fee: $20.00 All promotion examination fees are extra.

Personal Information

Driver's License Number _____________________  Social Security Number _________________________

Name _____________________________________________________  Age _________  Sex _________

Current Address _____________________________________  City __________  State ____  Zip _______

Work Address ______________________________________  City __________  State ____  Zip _______

E-Mail Address _____________________________________

Telephone-Home ____________________________  Telephone-Work ____________________________

Date of Birth __________________________  Height ________  Weight _________    [] Married    [] Single

Citizen of U.S.A. [] Yes   [] No  Occupation __________________________________________________

Referred By __________________________________________________________________________

Physical Record

List any physical defects _________________________________________________________________

____________________________________________________________________________________

What foreign languages can you speak fluently? ________________________________________________

___________________________________ [] Read   [] Write

All classes, practice sessions, and contests conducted by your instructor or master are supervised with reasonable care taken to prevent any injury and to minimize accidents. However, because of the strenuous nature of Martial Arts and combative activities, no one can positively assure the student, member, or instructor that injury will not result during practice sessions, instructional periods, and contests.

THEREFORE I, the above mentioned student, do hereby for myself, my heirs, executors, administrators, and assigns waive, release, and forever discharge any and all rights and claims whatsoever for damages which I may have, or shall hereinafter accrue to me, against my instructor, master, or to other members, for any and all damages which may be sustained and suffered by me in connection with my association or entry in any practice, class, contest, or athletic events, or which may arise out of my traveling to, participating in, or returning from such endeavor.

Student agrees to keep and obey all rules and regulations now in force or in the future prescribed by the Martial Art or its associated martial arts, for the use of martial arts and the equipment and facilities therein including rules with respect to lockers, uniforms, and personal hygiene and the Martial Art reserves the right to revoke this membership if student fails to keep and obey any of such rules and regulation or for reasons of nuisance, disturbance of other students, moral turpitude, or fraud. Positively No Refunds on any amount paid for registration fee, tuition fee, uniforms, or any other deposits made.

Student Signature _________________________________________  Date ________________________

Parent/Guardian Signature ___________________________________  Date _______________________

Authorized Signature _______________________________________  Date _______________________

======================Applicants: Do not write below this line.=======================

Type of Martial Arts ______________________________________________

Schedule of Payment ______________________________________________

Enrolled for _____________________________  Program _____________  Class __________________

Chapter Code ______________________  Student's I.D. Number _______________________________